Affordable Care Act: No impact on Tricare, but some coverage isn't equal

Sep. 26, 2013 - 04:42PM
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Tricare beneficiaries should see little impact from implementation of the Affordable Care Act because the military health care system was excluded from the law and Congress later passed legislation defining Tricare as meeting the act’s insurance coverage requirements.

But as seen immediately after the law’s passage, the omission of Tricare left military families out of at least one benefit — a provision that extended parents’ health care coverage to unmarried children up to age 26 — and there may be more, including the much-anticipated changes to mental health treatment and weight management.

While Tricare largely is viewed as a comprehensive health care program, there are disparities between the military plan and the ACA’s requirements of private insurers and state exchanges. Congress rectified the oversight of coverage for unmarried children by approving the Tricare Young Adult program shortly after the law passed, but additional changes may be needed, especially in the area of mental health, to bring the military program into line with the law.

“Despite sustained effort to improve screening, assessment and treatment capacity, the Defense Department and Veterans Affairs have a long way to go,” noted National Alliance on Mental Illness officials in a 2012 report, “Parity for Patriots.”

For instance, the ACA expands previous legislation requiring insurers to cover mental health and substance use treatment on par with care needed to treat physical conditions.

The law states that mental health and substance use disorder coverage must be provided as an essential benefit “comparable to general medical and surgical coverage.” It does not define what constitutes necessary care; many mental health specialists interpret this to mean appropriate care recommended by a physician.

But many insurers, including Tricare, place limits on mental health and substance abuse treatment. For example, acute in-patient mental health treatment is restricted to 30 or 45 days per fiscal year, depending on age, and beneficiaries other than active duty troops who need more than eight outpatient behavioral health care visits in a fiscal year must request authorization.

Some argue such limits do not meet the requirements for parity.

“More subtle forms of insurance discrimination, such as increased prior authorization restrictions for specific mental health benefits, exclusion of entire categories of services and more aggressive restrictive management of benefits, have kept the law from achieving its full, intended potential,” according to the NAMI report.

Another disparity lies in the field of weight loss. On one hand, Tricare covers bariatric surgery for the morbidly obese — a benefit many insurers aren’t required to pay for — but it doesn’t cover office visits for the treatment of obesity, non-surgical procedures for weight loss, weight-loss medications, or nutrition and diet counseling.

The ACA requires insurers to cover obesity screening, counseling and referrals. And at the state exchanges, the obese are entitled to intensive behavioral counseling and at least one prescription drug for obesity treatment.

Pregnant moms in Tricare may be dismayed to find that the ACA requires insurers to pay the full cost of breast pumps, but Tricare does not. It pays only for efficient electric breast pumps in hospitals and under certain circumstances for premature infants.

“I’m just shocked,” said Emily Cohen-Moreira, a New York City-based childbirth educator and lactation consultant. “Pretty much all of my students — those with private insurance and those on Medicaid — are covered now because of the Affordable Care Act. But not my military client.”

For a least one segment of the Tricare population — tobacco users — the military program’s exemption from the law is a boon to their wallets. Under the ACA, smokers and users of smokeless tobacco can be charged up to 50 percent more in premiums than non-smokers at the state-run health exchanges, and many insurance companies already charge smokers higher premiums.

But in Tricare, enrollment fees, co-payments and cost-shares are not based on a beneficiaries’ habits or health care requirements.

It would take an act of Congress to charge Tricare patients who smoke or are overweight higher health care enrollment fees, co-payments or a surcharge.